Challenges and Changes in Mexico After the Influenza AH1N1 Outbreak

From Standard ICU to Tele Presence with Robotics and Tele-Ultrasound

From March to December 2009, the Influenza
AH1N1 outbreak was observed in several cities of Mexico, showing deep flaws in
the healthcare system and a general lack of knowledge on how to act and react
in case of an epidemic. Because of that, thousands of people got infected and
high mortality was observed in intensive care units (ICUs). Since then, the
fragile healthcare system, particularly that of intensive care, has been
recuperated through a number of programmes and initiatives, which are discussed
in this article.

Health System Improvement

Mexico comprises of 32 states and has a total population of 103
million people, two thirds of whom have access to social security. Since the
AH1N1 pandemic three years ago, an increase of medical coverage became
available. Mexican health authorities have focused on improvement through
enhancing a programme called Seguro Popular, which has been functioning since
2003, ensuring medical attention to Mexican citizens, particularly the
vulnerable population. Nearly half of the country’s population is now enrolled
(Vence 2012) reaching almost universal healthcare coverage—many of whom prior
to this had no insurance to cover medical expenses.

The programme has increased the number of high care general hospitals
and primary care clinics in remote cities and fully equipped general hospitals
in small cities, preparing them for taking care of critical patients. It has
increased the number of ICU beds; improved several monitoring systems; and in
some places introduced diagnostics equipment like portable ultrasound for acute
areas. A significant amount of mechanical ventilators have been added to ICUs
and some high care hospitals, and high frequency oscillatory ventilators have
been included as rescue therapy for acute respiratory distress syndrome.
Regional high care hospitals have been created and improved in every state,
among them high care hospitals for obstetrical patients and other vulnerable
members of the population (pediatrics and neonatology).

An Enhanced ICU System

Since the revelation of flaws in the healthcare system, made
evident by the AH1N1 pandemic, the Mexican health
system has been preparing the population, providing them with information about
how to prevent influenza as well as primary care measures for avoiding transmission
of the virus and mortality. In addition, it has supplied statistics, symposiums
for gaining knowledge, and improved equipment and supplies. Important campaigns
for promoting sanitary measures (such as hand washing, and vaccination for
influenza) have been established on every level. The Mexican Critical Care Society
has been training intensivists in critical care ultrasound through World
Interactive Network Focused on Critical Ultrasound (WINFOCUS) programmes.

With regard to biological threats, it is crucially important to
improve efficient medical attention for critically ill patients, protect health
workers from highly virulent viruses or bacteria, or both, and decrease
mortality by carefully monitoring vulnerable patient populations during outbreaks.
These strategies were continued after the outbreak and adapted to the newly
established approach of intra hospital epidemiologic vigilance. Since
the outbreak of influenza AH1N1, healthcare professionals in Mexico have worked
every day to promote the country’s specialty as well as to increase the standard
of safety and care to international levels. For that reason, the Ministry of
Health, together with a multidisciplinary team, is working to map out
directives on the minimal equipment and supplies needed for ICUs to guarantee
medical attention for severely ill patients under extreme circumstances. A
Mexican national norm for ICUs was written via the collaboration of Mexican authorities
with the three major critical care societies: the Mexican College of Critical
Care Medicine, the Mexican Association of Pediatrics in Intensive Care and the Mexican
Association of Pediatrics. The main objective of the Mexican norm for ICUs is
to improve ICU system quality all over Mexico.

The programme has played a major role in intra hospital infection and
disease control as well as increasing the level of security for patients during
hospitalisation. The Mexican Academy of Surgery and other Mexican medical
associations, including the Mexican College of Critical Care Medicine, released
campaigns promoting sanitary measures and vaccination for influenza. Specific
clinical guidelines for the 10 major diseases are distributed to ICUs in both
public and private hospitals so as to standardise admission and treatment in
ICUs (www.salud.gob.mx).

Robotics in the ICU

Innovative strategies for attending to patients during the
pandemic were observed and adopted, including the use of telepresence with
robots at suburban hospitals. This came about after the increase of hospitals,
clinics and ICU beds created a lack of intensivists for full 24-hour coverage,
seven days per week in several units, particularly those located in small
cities away from the high care hospitals. Telepresence allows the distance and
time for diagnosis to be shortened considerably, further allowing the start of
specialised medical attention for a critically ill patient. It also supports
the nursing team and other medical fellows. Its use has resolved one of the
major problems in the ICU—the lack of intensivists. Critically ill patients in
towns and cities that are geographically distant from high care hospitals can
thus receive specialised medical assistance and
attention, meaning that the quality and safety of care during hospitalisation in
the ICU is increased.

Originally,
this novel programme assisted three suburban hospitals in the State of Mexico,
acute care facilities, including emergency rooms, ICUs, and isolated areas for
influenza. The programme showed that it is feasible to provide assistance from highly
specialised physicians to distant communities during an outbreak of influenza.
In addition, it has aided in the acquisition of medical reports, nurse’s reports
and laboratory results, as well as supervision of ventilator settings and
provision of advice regarding guidelines, all of which may result in increased quality
and safety of medical care in the ICU.

The Institute of Health of the State of Mexico is leading and
coordinating the telepresence experience in Mexico by using robots in acute
care facilities. From August 2009 to December 2011, more than 850 interventions
took place using the RP-7i® robot. Generally, optimal Internet broadband
connection was available, thus providing good video images and clear audio sounds.
Malfunctions were mainly due to Internet network failure at the suburban hospitals.
Medical staff, patients and their relatives easily accepted the programme and were
highly confident about the expertise offered. The success of the programme has
led to its broad employment, with four new robots added to the programme
covering all regions of the state.

Echocardiography and Ultrasound in ICU

In recent years, the availability of portable and relatively
inexpensive ultrasound units has made the technology a viable option for imaging
in rural and underdeveloped clinics. Today, the use of Internet protocol
transmission has proved its feasibility through the use of broadband with image
compression technology. After the images are transmitted, either as
asynchronous or synchronous sonograms, a remotely located expert can interpret
them.

According to WHO, diagnostic imaging is a requirement for the
accurate treatment of at least a quarter of all patients worldwide. Despite that, some areas, though they have access to second-level
hospitals, including emergency room services, ICU radiology, CT scanning and
ultrasonography, among other facilities, do not often have sufficient access to
them for performing a directed, protocolised diagnosis in acute care areas.
This can be achieved via the extended Focused Assessment with Sonography for
Trauma (FAST) protocol and pulmonary ultrasound.

Tele-Ultrasound

New practice opportunities are emerging for intensivists:
echocardiography, telepresence with robots in remote ICUs, and the combination
of both strategies. We could say that technology and telecommunications applied
in the ICU have created a new paradigm for critical care practice, extending
the coverage of specialised critical care to middlelevel hospitals in standard
cities. The resulting new era of telemedicine and e-health services has taken
advantage of technological advances and has successfully broken geographical
and socioeconomic barriers.

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